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SERVICE REQUEST ' <br /> Ty e o Bu fines o Pro rty FACILITY ID# SERVICE REQUEST# <br /> o-3 <br /> OwN I OPERAroa ,� , BILLING PARTY4,0 P <br /> ❑ <br /> FACILITY NAME OACO <br /> L�/j lt ?13 <br /> $READDRESS �T '/��( /]� r <br /> I �O SMet Number Direca'on `n t -\ WW Name (•tit'1 �t A �yp� SuN�/ <br /> Mailing Address (If Di Brent from Site Address) <br /> SOX 60 <br /> -7 <br /> C" �, n�/l 4)cw� <br /> STAT n zip � 0(e�l U V`- <br /> PHONE#'I Exr• AP # LAND USE APPLICATION# <br /> c � �7� — ( 3Lf 5 <br /> 7 : <br /> PHONE#2 / n /, W. BO DISTRICT LOCATION CODE <br /> Pol IQ <br /> ` - Ir Y <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PART'S <br /> BUSINESS NAME PHONE# <br /> MAILING ADDRESS �� �� t/� , _ FAX# I `, <br /> CITY TE ZIP Cr F��/ e� <br /> BILLING AC NOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge Uiat all site and/or project specific <br /> PUBLIC HEALTH SERVICES E r <br /> ONMENTAL HEALTH DnnsloN hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have pr pared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes.Standards,STATE and <br /> FEDERAL la`MS. ( (--Z:l <br /> 0�=d <br /> APPLICANT SIGNATURE: ANADATE�6w <br /> / <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MGER C1OMERAUTHORIZEDAGENT �� l `> <br /> I(Arwuc wr is not the B411+c Pim proof of suthorhat/on to slpn Is MuBvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geolechnical data and/or environmentallsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERvicEs ENVtRONM[NTAL HEALTH DIVISION as soon <br /> as it Is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: us /� f <br /> COMMENTS: <br /> PAY M Eli 1 <br /> RECEIVED <br /> AFP 2 8 2001 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> �NVIRONHENTAL HEAtTH')IMI,-I>. <br /> INSPECTOR'S SIGNATURE' CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: G((S DATE: <br /> 4 <br /> ASSIGNED TO: EMPLOYEE 9: 7 Zfi DATE: p <br /> Date Service Completed (if already completed): V SERVICECODE: tit PIE: <br /> Fee Amount- 7 ``— Amount Paid ,. ty-7 — Payment Date <br /> X280 <br /> Payment Type j Invoice 9' Check 9 ;7, i Received B <br />